Narrative interventions for health screening behaviours: A systematic review

Didactic and narrative persuasion: An experiment to promote colorectal cancer screening

We tested whether a didactic and a narrative video (i.e. educational content and personal stories versus irrelevant information) could boost colorectal cancer (CRC) screening intention directly and through cognitive predictors of CRC screening behavior. We also tested whether exposure to a story changed participants' affective forecasting, reducing the perception of negative emotions associated with CRC screening (disgust, embarrassment, and fear). The study was conducted online with a between-participants design and recruiting a convenience sample (N = 375). We found that, compared with watching the control video, being exposed to the narrative video about CRC screening was indirectly associated with greater screening intention via vicarious experience and positive attitudes, whereas watching the didactic video was positively associated with CRC screening intention only among participants who had received an invitation letter but did not get screened, and among those yet to receive an invitation to screen. In the latter group, screening intention was boosted through positive attitudes. Our findings do not confirm that stories change affective forecasting, but narration likely fosters messages acceptance through vicarious experience. We also found support for the effectiveness of physicians' recommendations in promoting CRC screening, an intervention that might be effectively administered through a generalized, cost-effective video.

Applying the framework for developing and evaluating complex interventions to increase family communication about hereditary cancer

Objective

Evaluate an intervention to increase family communication (FC) of positive hereditary cancer test results using the Framework for Developing and Evaluating Complex Interventions (FDECI).

Methods

We developed 'programme theory' during the FDECI development phase by aligning intervention components with behavior change techniques (BCTs) and theoretical factors expected to improve FC. During the feasibility phase, we obtained feedback from 12 stakeholder interviews.

Results

Intervention components aligned with a total of 14 unique BCTs for which prior evidence links the BCT to theoretical factors that influence behavior change. Constructive stakeholder feedback included: more information desired, rewording to support autonomy by highlighting options, and improvements to navigation, visuals, and audio. Positive comments included: comprehensiveness of materials, modeling of conversations, and usefulness of the materials for helping a person prepare to share positive test results.

Conclusion

The first FDECI phases were helpful for improving the intervention and planning our ongoing effectiveness and future implementation phases.

Innovation

Our application of the FDECI is novel, including plans to test our 'programme theory' using coincidence analysis (CNA) to determine who accesses which intervention materials, how utilizing certain materials impact the aligned theoretical factors, and whether these in turn make a difference in the behavioral outcome.

The Use of Narrative in Science and Health Communication: A Scoping Review

BACKGROUND

Many people deny science and reject health recommendations despite widely distributed facts and statistics. Didactic science and health communication is often dry, and relies on the false assumption that people make purely evidence-based decisions. Stories can be a powerful teaching tool by capturing attention and evoking emotion.

OBJECTIVE

We explore the impact and appeal of, and describe best practices for, using narrative (storytelling) versus didactic methods in science and health communication.

PATIENT INVOLVEMENT

No patients were involved in the review process.

METHODS

We searched PubMed and Web of Science for articles either: assessing effectiveness of narrative science/health communication; assessing acceptability of (or preference for) narrative science/health communication; giving advice on how best to use narrative; and/or providing science-based explanations for how/why narrative succeeds.

RESULTS

Narrative science/health communication is effective and appealing for audiences across a variety of topics and mediums, with supporting evidence across fields such as epidemiology, neuroscience, and psychology. Whether narrative or didactic messaging is most effective depends on the topic, audience, and objective, as well as message quality. However, combining narrative with didactic methods is likely to be more effective than using either strategy alone.

DISCUSSION

Narrative science/health communication merits wider implementation and further research. Narrative communication creates openness to information by delaying the formulation of counterarguments.

PRACTICAL VALUE

Science and health communicators should collaborate with cultural and storytelling experts, work directly with their target audiences throughout the message development and testing processes, and rely on popular story elements (e.g., first-person point of view, relatable protagonists) to improve the comprehension, engagement, and thoughtful consideration of their intended audience.

FUNDING

This work was funded by Thirty Meter Telescope, with which two authors (GKS and SD) were affiliated. Otherwise, the funding organization had no role in the study and/or submission.

"Each Day We Lose a Little More": Visual Depictions of Family Caregiving for Persons with Dementia

More than 11 million Americans provide unpaid care for people with dementia (PWD) and need emotional, financial, and physical support. This study explored how participants in Caregiver Speaks, a social networking and image-based storytelling intervention designed to help caregivers make meaning of caregiving, described their caregiving experiences and needs. Strategies of thematic analysis were used to identify patterns in 28 different caregivers' images (N = 59) and text interactions on social media. Caregivers identified as white (71.4%), as women (92.9%), and as an adult child or child-in-law of the PWD (85.7%). Through images and text, caregivers explained interrelated changes in their behaviors (e.g., managing dual roles), thoughts (e.g., realizing severity of illness), and feelings (e.g., trapped) throughout the caregiving process. Findings reiterate that caregiving changes significantly over time, that visual storytelling helps to concretely capture those changes, and that interventions are needed to respond to caregivers' hardships across the caregiving time span.

Developing an Educational and Decision Support Tool for Stage I Lung Cancer Using Decision Science

BACKGROUND

Guidelines recommend shared decision-making about treatment options for high-risk, operable stage I lung cancer. Patient decision aids can facilitate shared decision-making; however, their development, implementation, and evaluation in routine clinical practice presents numerous challenges and opportunities.

METHODS

The purpose of this review is to reflect on the process of tool development; identify the challenges associated with meeting the needs of patients, clinicians from multiple disciplines, and institutional workflow during implementation; and propose recommendations for future clinicians who wish to develop, refine, or implement similar tools into routine care.

RESULTS

In this review, we: (1) discuss guidelines for decision aid development; (2) describe how we applied those to create an education and decision support tool for patients with clinical stage I lung cancer deciding between radiation therapy and surgical resection; and (3) highlight challenges in implementing and evaluating the tool.

CONCLUSIONS

We provide recommendations for those seeking to develop, refine, or implement similar tools into routine care.

Developing theory-driven narrative messages with personal stories: A step-by-step guide

OBJECTIVE

Narratives are commonly utilized in health promotion and behavior change interventions due to their efficacy over didactic or expository interventions. While grounding narratives in behavioral theory may render them more effective, balancing the integration of theoretical and creative aspects of the narrative development process while maintaining authenticity is challenging. Thus, this manuscript describes a rigorous process through which researchers can intentionally integrate theory and personal stories for health interventions.

METHODS

The process for creating theory-driven narratives involves the following steps: (1) defining the purpose of the narratives, (2) selecting a guiding theory, (3) collecting personal testimonials, (4) immersing self into testimonials, (5) identifying central narratives and important variations, (6) considering additional theories, (7) piecing quotes into cohesive stories, (8) filling in the gaps, and (9) checking for resonance.

RESULTS

To exemplify this step-by-step process, we provide a case study from our research involving the development of a psychoeducational intervention to model information seeking strategies for managing cancer-related uncertainty among women who have recently tested positive for pathogenic genetic variants that increase risk for hereditary breast and ovarian cancer.

CONCLUSIONS

We discuss special considerations for developing theory-driven narrative interventions and reflect on how this rigorous step-by-step process can be adapted by other researchers.

The Effects of the Type of Information Played in Environmentally Themed Short Videos on Social Media on People’s Willingness to Protect the Environment

This study used a 2 × 2 experimental design to explore the effects of message type (non-narrative vs. narrative information) and social media metrics (high vs. low numbers of plays) of low-carbon-themed social media short videos on people’s willingness to protect the environment. Subjects completed questionnaires after viewing short videos that contained different message types and social media metrics, and a final sample of 295 cases was included in the data analysis. The study found that, while the type of information (i.e., non-narrative or narrative) of the low-carbon-themed social media short videos had no direct effect on people’s willingness to protect the environment, its indirect effects were significant. These indirect effects were achieved through immersion experience and social influence. Subjects who watched narrative videos had a higher level of immersion experience, which in turn was significantly and positively correlated with environmental intention; meanwhile, those who watched non-narrative videos experienced a higher level of social influence, which in turn was significantly and positively correlated with environmental intention. In addition, subjects who viewed high-volume videos experienced a more positive effect on their willingness to protect the environment. This study explored how message design could promote subjects’ perceptions and positive attitudes towards environmental protection, with important managerial implications.

Investigating the Persuasive Effects of Testimonials on the Acceptance of Digital Stress Management Trainings Among University Students and Underlying Mechanisms: A Randomized Controlled Trial

Objective: This experiment aims to investigate the influence of narrative information varying in the degree of perceived similarity and source credibility in supplemented testimonials on the acceptance of digital mental health services (digi-MHSs).

Methods: In fall 2020, n=231 university students were randomly assigned to an active control group (aCG, n=55, “information only”) or one of three intervention groups (IGs) receiving information plus different testimonials being presented either by nonacademic staff (IG1, n=60), university students (IG2, n=58) or experts (IG3, n=58). We assessed mediation effects of similarity and credibility on acceptance in terms of attitudes and usage intentions.

Results: Exposure to testimonials was associated with higher usage intentions (d=0.50) and more positive attitudes toward digi-MHSs (d=0.32) compared to mere information (aCG). Regarding source-related effects, one-way ANOVA showed group differences in intentions (ηp2=0.13) that were significantly higher after exposure to testimonials targeted at students than in the other groups after adjusting for baseline intentions (ηp2=0.24). Concerning underlying mechanisms, there were full mediation effects of similarity (IG1 versus IG2) on attitudes [95%CI (0.030, 0.441)] and intentions to use digi-MHSs [95%CI (0.100, 0.528)] and of credibility on attitudes [IG2 versus IG3; 95%CI (−0.217, −0.004)], all favoring students’ testimonials.

Conclusion: Overall, this study indicates that the acceptance of digi-MHSs can be substantially increased by providing a simple, context-sensitive information intervention, including testimonials by university students. Since we identified mediating effects of credibility on cognitive attitudes and similarity on affect-driven intentions, a future trial could vary these features using narrative versus statistic information on digi-MHSs.

Focus groups and interviews with the public led to the development of a template for a GRADE Plain Language Recommendation (PLR)

OBJECTIVE

Clear communication of health care recommendations to patients and the public is essential. Current work has focused on creating patient versions of guidelines without much attention to single recommendations. In this study, we built on previously conducted research to test a template and explore the public's perceptions of, and attitudes towards plain language guideline recommendations.

STUDY DESIGN AND SETTING

We conducted four focus groups with people interested in healthy aging to obtain general attitudes, perceptions, and understanding of recommendations. We then conducted nine user-tests of Plain Language Recommendations developed from GRADE guidelines. We performed a directed content analysis, and finalized a template for a Plain Language Recommendation.

RESULTS

We identified themes related to personalized information; strength of recommendations; support with health care and appointments; amount and credibility of information; and formatting. When recommendations were conditional, participants wanted more information about why and what to consider. The template for a Plain Language Recommendation is available in the GRADEpro software to facilitate automation.

CONCLUSION

We created a Plain Language Recommendation template to communicate specific information from guidelines to patients and the public. Broad application of the template is warranted and future research could measure the impact on understanding and behavior change.

Do Personal Stories Make Patient Decision Aids More Effective? An Update from the International Patient Decision Aids Standards

BACKGROUND

This article evaluates the evidence for the inclusion of patient narratives in patient decision aids (PtDAs). We define patient narratives as stories, testimonials, or anecdotes that provide illustrative examples of the experiences of others that are relevant to the decision at hand.

METHOD

To evaluate the evidence for the effectiveness of narratives in PtDAs, we conducted a narrative scoping review of the literature from January 2013 through June 2019 to identify relevant literature published since the last International Patient Decision Aid Standards (IPDAS) update in 2013. We considered research articles that examined the impact of narratives on relevant outcomes or described relevant theoretical mechanisms.

RESULTS

The majority of the empirical work on narratives did not measure concepts that are typically found in the PtDA literature (e.g., decisional conflict). Yet, a few themes emerged from our review that can be applied to the PtDA context, including the impact of narratives on relevant outcomes (knowledge, behavior change, and psychological constructs), as well as several theoretical mechanisms about how and why narratives work that can be applied to the PtDA context.

CONCLUSION

Based on this evidence update, we suggest that there may be situations when narratives could enhance the effectiveness of PtDAs. The recent theoretical work on narratives has underscored the fact that narratives are a multifaceted construct and should no longer be considered a binary option (include narratives or not). However, the bottom line is that the evidence does not support a recommendation for narratives to be a necessary component of PtDAs.

A Qualitative Study on the Impact of First Steps-A Peer-led Educational Intervention for People Newly Diagnosed with Parkinson's Disease

Aim: The dual aim of this research was to consider the impact of providing the First Steps program on the stories of people with Parkinson's Disease (PD) and to investigate the psychosocial and emotional mechanisms which may explain this impact. Methods: A qualitative study using a subtle realist paradigm and hermeneutic phenomenological methodology was undertaken. A single semi-structured interview was used to consider the impact and experiences of people with PD who completed either the intervention (2-day peer-led behavior intervention using storytelling 6-8 weeks apart) or received telephone support calls as part of the active control group. Descriptive statistics and a narrative analysis were undertaken on the results. Results: Forty-two participants were invited to participate, forty of whom completed the interview. This included 18 from the intervention group and 22 from the active control group. The intervention group identified the value of the program as worth-while, demonstrating improved exercise behavior and coping mechanisms following the intervention. Three major stories (the affirmed, the validated and the transformed story) identified the impact of the intervention. Three internal mechanisms (perceived control, hope and action, and the individual's mind set) alongside three social mechanisms (social comparison, social control and the first opportunity to share with peers) appeared to explain this impact. Conclusion: This study provides exciting and novel evidence of the impact of a peer-led psycho-educational intervention for people newly diagnosed with PD. Further research is needed to consider the impact of stories-based approaches on participants and consider a critical evaluation of the mechanisms which may explain changes in stories and self-reported behaviour.

Improving Adherence to Colorectal Cancer Screening: A Randomized Intervention to Compare Screener vs. Survivor Narratives

Interventions are needed to increase colorectal cancer screening (CRCS) uptake. Narratives may have advantages over didactic information. We tested different narratives for increasing CRCS intentions and behaviors, and examined their mechanisms of influence. We randomized 477 unscreened adults 50-75 years old to one of three groups: CRCS information only (1) or CRCS information plus a photo and text narrative of a CRC survivor (2) or CRC screener who did not have cancer (3). Photos were tailored on participants' sex, age group, and race/ethnicity. Participants completed online surveys before and after intervention exposure, and 1-, 6-, and 12-months follow-up. Thirty percent of participants completed CRCS. Narrative conditions (vs. information only) were negatively associated with intention, but also positively influenced intentions through greater emotional engagement. Survivor (vs. screener) narratives were positively associated with CRCS, and had mixed effects on intention - positively through emotional engagement and negatively through self-referencing engagement to self-efficacy. Survivor narratives elicited more negative affect, which had positive and negative influences on intention. Continued research using path models to understand the mechanisms of narrative effects will inform theory development and message design. Additional measurement evaluation is needed to adequately capture and then compare the effects of different components of narrative engagement.

Using narratives to impact health policy-making: a systematic review

BACKGROUND

There is increased interest in using narratives or storytelling to influence health policies. We aimed to systematically review the evidence on the use of narratives to impact the health policy-making process.

METHODS

Eligible study designs included randomised studies, non-randomised studies, process evaluation studies, economic studies, qualitative studies, stakeholder analyses, policy analyses, and case studies. The MEDLINE, PsycINFO, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL), WHO Global Health Library, Communication and Mass Media Complete, and Google Scholar databases were searched. We followed standard systematic review methodology for study selection, data abstraction and risk of bias assessment. We synthesised the findings narratively and presented the results stratified according to the following stages of the policy cycle: (1) agenda-setting, (2) policy formulation, (3) policy adoption, (4) policy implementation and (5) policy evaluation. Additionally, we presented the knowledge gaps relevant to using narrative to impact health policy-making.

RESULTS

Eighteen studies met the eligibility criteria, and included case studies (n = 15), participatory action research (n = 1), documentary analysis (n = 1) and biographical method (n = 1). The majority were of very low methodological quality. In addition, none of the studies formally evaluated the effectiveness of the narrative-based interventions. Findings suggest that narratives may have a positive influence when used as inspiration and empowerment tools to stimulate policy inquiries, as educational and awareness tools to initiate policy discussions and gain public support, and as advocacy and lobbying tools to formulate, adopt or implement policy. There is also evidence of undesirable effects of using narratives. In one case study, narrative use led to widespread insurance reimbursement of a therapy for breast cancer that was later proven to be ineffective. Another case study described how the use of narrative inappropriately exaggerated the perceived risk of a procedure, which led to limiting its use and preventing a large number of patients from its benefits. A third case study described how optimistic 'cure' or 'hope' stories of children with cancer were selectively used to raise money for cancer research that ignored the negative realities. The majority of included studies did not provide information on the definition or content of narratives, the theoretical framework underlying the narrative intervention or the possible predictors of the success of narrative interventions.

CONCLUSION

The existing evidence base precludes any robust inferences about the impact of narrative interventions on health policy-making. We discuss the implications of the findings for research and policy.

TRIAL REGISTRATION

The review protocol is registered in PROSPERO International prospective register of systematic reviews (ID =  CRD42018085011 ).

Effects of an entertaining, culturally targeted narrative and an appealing expert interview on the colorectal screening intentions of African American women

Universal screening for colorectal cancer (CRC) is recommended for individuals 50-75 years of age, but screening uptake is suboptimal and African Americans have suffered persistent racial disparities in CRC incidence and deaths. We compared a culturally tailored fictional narrative and an engaging expert interview on the ability to increase intentions to be screened for CRC among African American women. In a post-only experiment, women (N = 442) in face-to-face listening groups in African American churches heard audio recordings of either a narrative or an expert interview. Questionnaires were completed immediately afterward and 30 days later. Women who heard narratives reported stronger intentions to be screened with a home stool blood test than women who heard the interview; the effect lasted at least 30 days. Culturally tailored, fictional narratives appear to be an effective persuasive strategy for reducing racial disparities in CRC outcomes.

Exploring breast health practices of post-menopausal women: Implications to informed consent

In light of the contention surrounding breast health practices, the research aimed to explore post-menopausal women's experiences of such practices. Semi-structured interviews were conducted in July and August 2015 with 13 Australian women aged 54-74 years. Data were analysed thematically. Participants deemed their engagement with breast health practices as the 'right' thing. However, engaging in these 'right' practices appeared to be fostered by misconceptions. The findings suggest that women may not be making evidence-informed decisions to engage in breast screening; identify contemporary barriers to promoting informed decisions; and may inform information pertinent to breast screening policy, campaigns and decision aid designs.

Online training improves paramedics' knowledge of autonomic dysreflexia management guidelines

STUDY DESIGN

Single-group pre-/post-test with 3- and 6-month follow-ups.

OBJECTIVES

To test the effects of the 'ABCs of AD' educational module on immediate and longer-term changes in paramedics' knowledge and beliefs about using the autonomic dysreflexia clinical practice guidelines (AD-CPGs).

SETTING

Canada.

METHODS

A total of 119 paramedics completed an AD knowledge test and measures of attitudes, perceived control, self-efficacy, social pressure from patients and health-care professionals, and intentions to use the AD-CPGs before and 1 week, 3 months and 6 months after viewing 'ABCs of AD'.

RESULTS

There were significant improvements in AD knowledge, attitudes and social pressure from patients to use the AD-CPGs from baseline to 1 week, 3 months and 6 months post viewing (all P<0.001). Self-efficacy and intentions increased 1 week post viewing (P<0.001), but returned to baseline levels at 3 and 6 months (P>0.05). There was no change in perceived control or social pressure from health-care professionals. AD knowledge and beliefs explained 50-61% of the variance in intentions to use the AD-CPGs. Attitudes, social pressure from patients and perceived behavioural control were significant unique predictors of intentions at all time points (P<0.05); AD knowledge was a significant predictor at 6 months only (P=0.048). No other predictors were significant.

CONCLUSION

'ABCs of AD' has immediate and sustained effects on paramedics' knowledge of attitudes toward and perceived pressure from patients to use the AD-CPGs. Updates to paramedic patient care guidelines and standards are needed to increase paramedics' perceived control and self-efficacy to implement the guidelines, and their intentions to use the AD-CPGs.

SPONSORSHIP

Canadian Institutes of Health Research (2011-CIHR- 260877).